RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

KARNATAKA, BANGALORE

ANNEXURE – II

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1.

NAME AND ADDRESS OF

THE CANDIDATE

MR. MANJUNATHA RAO.S

I YEAR M.Sc.NURSING

INDIRA NURSING COLLEGE

FALNIR,

MANGALORE -575002

2. NAME OF THE

INSTITUTION

INDIRA NURSING COLLEGE

FALNIR,

MANGALORE -575002

3. COURSE OF THE STUDY,

SUBJECT

I YEAR M.Sc NURSING

MEDICAL SURGICAL NURSING

4. DATE OF ADMISSION TO

COURSE

15-07-2011

5. Title of the Topic

“A study to assess the knowledge and attitude regarding the use of

inhalers among bronchial asthma patient, attending outpatients

department’s of selected hospitals of Mangalore Taluk with a view to

prepare informational booklet”

1

6. B BRIEF RESUME OF THE INTENDED WORK:

6.1 INTRODUCTION

“The more deeper and more efficient that our breathing is, the pure is the blood, and

this in itself must result in better health”. - RON WILLEY

Breathing is a basic need. It is a physiological function that is almost

synonymous with being alive. There are several disorders that affect the movement

of air in and out of the lungs such as bronchitis, emphysema and asthma is often

occurred one. Asthma complex disorder involves biochemical, immunological,

endocrine, infectious, autoimmune, psychological factors. The word asthma is

derived from Greek word meaning ‘breathing or panting’ which is characterized by

wide spread narrowing of airway.1,

The prevalence of asthma has increased significantly since the 1970s as of

2009; 300 million people were affected worldwide. In India, asthma affects 2.38% of

the population and in Karnataka 3.47% of the population is affected by asthma.3

Inhaler usage is the best choice for the treatment of bronchial asthma than

the oral medication. Inhalers are different types. The use of inhaler involves co-

ordination with inspiration process. Due to the lack of knowledge regarding the

usage of inhalers the treatment and relief from bronchial asthma is not adequate.

Many members do not know at least the name of inhalers.

The value of inhalation as a route of drug administration has been

recognized for thousands of years by the ancient civilization in India the middle east

and as well as by a Hippocrates and Galen. The ayurvedic system of medicine

advocates the use dhatura smoked in a pipe for a variety of ailments and atropa

belladona was given by smoking as standard remedy for Asthma.

Bronchodilator aerosols have been used since 1935. In the adrenaline

bronchodilator have been given by hand hold squeeze bulb nebulizers.This was

cumbersome and modern pressurized aerosols were introduced in 1956 and

constituted a breakthrough in inhalation treatment. In recent times inhalation therapy

have higher level of sophistication although they are simple to use

Inhaled medications are administered directly to the airways, providing a higher

local concentration and a lower risk of systemic side effects. For years, jet nebulizers

were the only inhalation devices available; however, the development of other

2

devices (metered-dose inhalers, with and without spacers, and dry powder inhalers)

made it possible to improve the delivery of drugs to the lungs, as well as to decrease

local and systemic side effects.4

6.2 NEED FOR THE STUDY

Inhaler devices are an important part of the armamentarium of clinicians

who treat both these obstructive pulmonary diseases. The effectiveness of inhaled

drugs depends on the patients’ ability to use the inhaler device correctly and

adherence to the treatment regimens is likely to be influenced by their opinions and

feelings about the use of inhalers as a mode of therapy. The successful management

of COPD and asthma requires attention not only to the observable behavior of the

patients, but also to the underlying knowledge and attitudes which drive that

behavior. It is a well accepted fact that the patients’ views should be taken into

account during the medical decision-making and the choice of therapy.4

In India asthma prevalence has increased from 9 percent in 1979 to

29.5 percent in 1999.It is a major health burden in our country. It is estimated that the

chronic asthma cases in India will increase in number from 274.4 lakhs to 350.2

lakhs from 2001 to 2016.According to NFHS-2 report the estimated prevalence of

asthma in India is 2468 for 1 lakh population. The prevalence rate was 2309 among

those in the age group of 15-59 years. While it was 10375 in those above

60years.Asthma has recorded to be high in Karnataka above national average. The

prevalence of severe asthma in Bangalore has shown an increased and reached 6.5

percent during 1999.2

A study was conducted investigate ‘the attitudes, Beliefs and

Perceptions Regarding the use of Inhalers among 1276 COPD and asthma Patients

and 1832 General Population in Punjab. A questionnaire which could identify the

patients’ potential attitudes, beliefs and perceptions about inhalers was designed. The

Results showed that only 15.1% patients and 17.2% subjects from the general

population considered the use of Inhalers was a social stigma and preferred oral

medication they expressed their inhibitions for inhaler use in public, wanted to keep

the inhaler use as a secret, expressed preference for a smaller inhaler device and a

single dose inhaler and thought that inhalers are were used in for serious diseases

which once started on, inhalers had to be taken lifelong. Study concludes there are

misplaced beliefs, attitudes and perceptions about inhalers among a majority of 3

subjects will definitely inhibit the proper utilization of inhaler therapy. More

importantly, the results have necessitated the urgent need for an individual and a

collective national effort in the form of national educative programmes to dispel the

misconception and inadequate knowledge, beliefs, attitudes and the perceptions of

the patients and the common people towards inhalers.4

An observational study, To evaluate knowledge of and techniques

for using prescribed inhalation devices among 120 volunteers: 60 with asthma and 60

with COPD patients at Brazil the result showed that all of the asthma patients and

98.3% of the COPD patients claimed to know how to use inhaled medications. 113

patients (94.2%) committed at least one error when using the inhalation device.

Patients committed more errors when using metered-dose inhalers than when using

the dry-powder inhalers Aerolizer (p < 0.001) or Pulvinal® (p < 0.001), as well as

committing more errors when using the Aerolizer® inhaler than when using the

Pulvinal® inhaler (p < 0.05). Using the metered-dose, Pulvinal® and Aerolizer®

inhalers, the COPD group patients committed more errors than did the asthma group

patients (p = 0.0023, p = 0.0065 and p = 0.012, respectively). The study conclude

that although the majority of the patients claimed to know how to use inhalation

devices, the fact that 94.2% committed at least one error shows that their technique

was inappropriate and reveals a discrepancy between understanding and practice.5

Patients knowledge, attitude and practices play a important role in

understanding, defining, and responding to illness and so, this study was aimed to

exploring knowledge and attitudes and perception of the patients with regards to

inhalers as a treatment modality. People have different knowledge about the use of

inhalers in Asthma. Incorrect underlying knowledge belief and attitude about inhaler

use may constitute a major obstacle to the adherence to disease management and

other self management behavior, and such attitude thereby, may continue to poor

treatment outcomes.

With this study, it will enhance the use of inhalers and improve the patient’s

knowledge with regard to inhaler technique. It helps to improve the health status of

the Asthmatic patient.

6.3 REVIEW OF LITERATURE

4

A cross sectional descriptive study was conducted to assess the level

of knowledge regarding inhaler use among 298 chronic asthma patients attending

three Institutes of Dhaka. Convenient sampling was adopted. Data were collected

using one semi-structured questionnaire through face-to-face interview. Out of the

total 298 respondents 103(35.8%) possessed "excellent knowledge" on inhalers.

Ninety one (31.6%) had "adequate knowledge", sixty nine (24.0%) had "poor

knowledge" and 35 (8.7%) respondents were found having "no knowledge" about

inhalers. Males were seen having better knowledge than the females. The

respondents receiving treatment from the indoor possessed better knowledge than

those from the outdoors (p<0.001). Level of Knowledge was also found to be

associated with the educational status of the respondents. Respondents with higher

education possessed more than the respondents with lower education (p<0.001). the

result conclude that physicians now prescribe inhalers, but many of them do not

explain the proper use of inhaler. This may be corrected through training and

motivation of physicians at Medical Colleges and Hospitals and during various

medical conferences and other programs. To reduce the extent of suffering and

economic burden of asthma patients and their families, active education program for

the patients and training program for the health care providers, regarding "inhaler use

technique" demands early consideration.6

A experimental study to ‘assess the impact of an asthma education

programmed(AEP) on knowledge of asthma and medication, compliance to

treatment’ in urban hospital Singapore states that Patients hospitalized for asthma

exacerbation were administered a questionnaire to test their baseline knowledge and

beliefs on asthma, its medications and their compliance to treatment. Their inhaler

technique was assessed. They then underwent an AEP consisting of two

individualized education sessions. Re-testing was performed after three months. Per

protocol approach and McNamara’s test was used to analyze the statistical

significance of the change in the pre- and post-AEP test scores. Hospital

administrative data were used to determine the number of ED visits and hospital

admissions pre- and post-AEP. Results: Among the 67 patients who completed the

two-phase AEP, there was significant improvement in some knowledge aspects.7

A study on ‘Predictors of incorrect inhalation technique in patients with

asthma or COPD’ at Netherland. A validated scoring method was used that consisted

of triple viewing of video-recorded inhalations, using device-specific checklists. The 5

following patient characteristics were investigated: gender, age, education level,

diagnosis, treatment by a pulmonary physician, previously received inhalation

instruction, exacerbation frequency, knowledge, self-management competence,

pulmonary function, and use of multiple inhaler devices. Chi-square statistics were

used for univariate associations between potential determinants and correctness of

inhalation technique. Result showed that Overall, 40% of the patients made at least

one essential mistake in their inhalation technique. Patients who never received

inhalation instruction and patients who used more than one inhaler device made

significantly more errors (odds ratio both 2.2). The study conclude that Incorrect

inhalation technique is common among asthma and COPD patients in a pulmonary

outpatient clinic. Our study suggests that the use of prefilled dry powder inhalers as

well as inhalation instruction increases correct inhalation technique.8

A cross sectional study was conducted ‘to determine the prevalence of

an incorrect inhalation technique and to examine its determinant among primary care

patients of 558 asthma and COPD at Netherland. Inhalation technique was assessed

using a standardized inhaler-specific checklist. Pulmonary function assessment and

questionnaires were used to collect data about inhaler, patient and disease

characteristics. The results showed that overall, 24.2% of the patients made at least

one essential mistake in their inhalation technique. The type of inhaler appeared to be

the strongest independent determinant of an incorrect inhalation technique. The study

concluded that An incorrect inhalation technique is common among pulmonary

disease patients in primary care. Our study suggests that especially patients with

emotional problems and patients in a group practice are at increased risk for an

incorrect inhalation technique.9

An observational study on ‘Assessment of Handling of Inhaler devices in

real life’ among 3811 patient was performed in primary care at France,. 76% of

patients made at least one error with pMDI compared to 49-55% with breath-

actuated inhalers. Errors compromising treatment efficacy were made by 11-12% of

patients treated with Aerolizer®, Autohaler, or Diskus® compared to 28% and 32% of

patients treated with pMDI and Turbuhaler, respectively. Overestimation of good

inhalation by general practitioners was maximal for Turbuhaler (24%), and lowest

for Autohaler® and pMDI (6%). 90% of general practitioners felt that participation in

the study would improve error detection. These results suggest that there are

differences in the handling of inhaler devices in real life in primary care that are not 6

taken into account in controlled studies. There is a need for continued education of

prescribers and users in the proper use of these devices to improve treatment

efficacy.10

A cross sectional study on ‘Relationships between repeated instruction

on inhalation therapy, medication adherence, and health status on chronic obstructive

pulmonary disease’ among 88 patient at Japan. A self-reported adherence

questionnaire with responses on a 5-point Likert scale is used. Result showed that Of

the 88 patients who were potential participants, 55 (63%) responded with usable

information. Of the 55 respondents, 22 (40.0%) were given repeated verbal

instruction and/or demonstrations of inhalation technique by a respiratory physician.

Significant correlations were found between the overall mean adherence score and

the health-related quality of life score. Furthermore, patients with repeated

instruction showed better quality of life scores than those who did not receive

instruction. The study conclude that repeated instruction for inhalation techniques

may contribute to adherence to therapeutic regimens, which relates to better health

status in COPD.11

6.3 Problem Statement: -

“A study to assess the knowledge and attitude regarding the use

of inhalers among bronchial asthma patient attending outpatients

department’s of selected hospitals at Mangalore Taluk with a view to

prepare informational booklet”

6.4 Objectives of the study: - The objectives of the study are to :

assess, the knowledge of bronchial asthma patient about the use of inhalers

assess, the attitude of the bronchial asthma patient towards use of inhalers

find out the association between knowledge of bronchial asthma patients

regarding the use of inhalers and selected demographic variables

7

find out the association between attitude of the bronchial asthma patient

towards the use of inhalers and selected demographic variables

develop and validate an informational booklet.

6.5 Operational definitions: -

Knowledge : Refers to the level of awareness among selected subjects about use of

inhalers of bronchial asthma patients with structured questionnaire

Attitude: Refers to the belief and opinion of the bronchial asthma patients towards

the use of inhalers

Bronchial asthma: Refers to a condition of the lungs characterized by widespread

narrowing of the airways due to spasm of the smooth muscle, edema of the mucosa,

and the presence of mucus in the lumen of the bronchi and bronchioles. It is caused

by the local release of spasm gens and vasoactive substances in the course of an

allergic reaction.

Inhalers : Refers to a medical device used for delivering medication into the body

via the lungs used in the treatment of bronchial asthma

Informational booklet : Refers to a small bound book having a paper cover which

contains information about various ways to improve knowledge and attitude of

bronchial asthma patient regarding the use of inhalers

6.6 Assumptions: -

The study assumes that:

1. Bronchial asthma patients will have inadequate knowledge regarding use of

inhalers.

2. Bronchial asthma patients will have inappropriate attitude towards use of

inhalers.

3. Informational booklet will help to improve knowledge and attitude regarding use

of inhalers.

6.7 Delimitations: -

8

7

The study is limited to, Bronchial asthma patients

1. Who are using Inhalers.

2. Attending the out patients department in selected hospitals.

3. Willing participate in the study.

6.8 Hypotheses:- The study is based on the hypotheses:

H1 - There will be significant association between the knowledge with their

selected demographic variables

H2 - There will be significant association between the attitude with their selected

demographic variables

MATERIAL AND METHOD: -

7.1 Source Of Data Data will be collected from the bronchial asthma patients who are using Inhalers

attending outpatient department’s of selected hospital

7.1.1 Research Design

The design adopted is descriptive design.

7.1.2 SettingsOutpatient department’s of selected hospitals at Mangalore Taluk.

7.1.3 PopulationPopulation consists of bronchial asthma patients using inhalers attending outpatient

department’s of selected hospitals

7.2 METHOD OF DATA COLLECTION

7.2.1 Sampling procedure

Sampling procedure selected is Non-probability purposive Sampling

7.2.2 Sampling size Sample size consists of 60 bronchial asthma patients using inhaler attending

9

outpatient department’s of selected hospitals

7.2.3 Inclusion criteria for sampling Bronchial asthma patients:

1. Who are using inhalers.

2. Who fall into the age group of 20- 50years.

3. Who know to read Kannada.

7.2.4 Exclusion criteria for sampling Bronchial asthma patients:

1. who are not using inhalers

2. with old age

3. with Pregnancy

7.2.5 Instruments used Tool 1: Demographic Performa.

Tool 2: The structured knowledge questionnaire will be constructed

Tool 3: Attitude scale

7.2.6 Data collection method Data will be collected from 60 patients who are using inhaler by direct

administration of structured knowledge questionnaire and Attitude scale

.

7.2.7 Plan of data analysis: - It is done by using both descriptive and inferential statistics.

1. Knowledge and attitude will be analyzed by using mean, median, mean

percentage and standard deviation.

2. Chi-square test will be used to find out the association.

7.3 Does the study require any investigation to be conducted on patient or

other human or animals? If so please describe briefly?

Not applicable.

10

7.4 Has ethical clearance been obtained from your institution in case of

7.3?

Yes. .

LIST OF REFERENCES:

1. Lewis.et al., Nursing care in obstructive pulmonary disease. Medical

Surgical Nursing. Fourth edition; Missouri: Mosby; 1996.p. 682-683.

2. Murthy KJR.et al., Economic burden of Asthma NCMH background papers

– Burden of diseases in India. p. 251-259.

3. http://medind.nic.in/iae/t06/i1/iaet06i1p23.pdf.Accessed on 24 August 2009.

4. Vitull k. Gupta, jagjeet singh bahia, ashwani maheshwari, sonia arora,

varun gupta, sahil nohria.To study the attitudes, beliefs and perceptions

regarding the use of inhalers among patients of obstructive pulmonary

diseases and in the general population in punjab. Journal of Clinical and

Diagnostic Research [serial online] 2011June[cited:2011Nov20];5:434-

439. Available from - http://www.jcdr.net/back_issues.asp?

11

issn=0973-

5. Souza ML, Meneghini AC, Ferraz E, Vianna EO, Borges MC.,

Knowledge of and technique for using inhalation devices among

asthma patients and COPD patient, J.bras. pneumol. vol.35 no.9 São

Paulo Sept. 2009,Print version ISSN 1806-3713, availablefrom

URL- –http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1806-

37132009000900002&lng=en&nrm=iso&tlng=en.

6. Parvin IA , Ahmad SA, Islam MN. ‘Knowledge about inhaler use among the

chronic asthma patients in selected hospitals’. Bangladesh Med Res Counc

Bull. 2011 Aug;37(2):47-50.Source-College of Nursing, Mohakhali, Dhaka

Available from http://www.ncbi.nlm.nih.gov/pubmed/21877604

7. Prabhakaran L, Lim G, Abisheganaden J, Chee C B E, Choo Y M . assess

the impact of an asthma education programme(AEP) on knowledge of

asthma and medication, compliance to treatment’ in urban hospital

singapur, Singapore Med J 2006; 47(3) page no.225-231 :available from

URL-

http://www.ttsh.com.sg/uploadedFiles/TTSH/Medical_Professionals/

Nursing_TTSH/Nurse_Clinicians/Asthma_1.pdf

8. Rootmensen GN , van Keimpema AR, Jansen HM, de Haan RJ. Predictors

of incorrect inhalation technique in patients with asthma or COPD: a study

using a validated videotaped scoring method. J Aerosol Med Pulm Drug

Deliv. 2010 Oct;23(5):323-8. Available from; http://www.ncbi.nlm.nih.gov

9. Hesselink AE, Penninx BW, Wijnhoven HA, Kriegsman DM, van Eijk JT.

‘determinants of an incorrect inhalation technique in patients with asthma

or COPD’Scand J Prim Health Care. 2001 Dec;19(4):255-60.

10. M. Molimard, C. Raherison, S. Lignot, F. Depont, A. Abouelfath, and N.

Moore. Asessment of Handling of Inhaler devices in real life. journal of

Aerosol Medicine. September 2001: 281-287.. Available from

-http://www.liebertonline.com/doi/abs/10.1089/089426803769017613?

journalCode=jam

11. Takemura M, Mitsui K, Itotani R, Ishitoko M, et,al Division of

Respiratory Medicine, Tazuke Kofukai, Medical Research Institute, Kitano 12

Hospital ‘Relationships between repeated instruction on inhalation therapy,

medication adherence, and health status in chronic obstructive pulmonary

disease Available from

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3048085/?tool=pubmed

9 SIGNATURE OF CANDIDATE

10 REMARKS OF THE GUIDE

11.1 NAME AND DESIGNATION OF

GUIDE Prof . Jyothi N Tiwary

Principal

11.2

SIGNATURE

11.3 CO-GUIDE (IF ANY)

11.4 SIGNATURE

11.5 HEAD OF THE DEPARTMENT Mrs . Jyothi N Tiwary

Prof.

11.6 SIGNATURE

13

12.1 REMARKS OF THE PRINCIPAL

12.2 SIGNATURE

14